SCM (WI/OH) Wellness Completion Form

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* 1. Last

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* 2. First

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* 3. Associate ID# (This is NOT your Social Security #)

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* 4. Date of Birth (Used as a Confirming Identifier)

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* 5. Contact Information (Enter CORRECTLY as we will send a confirmation e-mail to this address).

Email Address

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* 6. Specify the program you have completed

Blood Pressure Program

Pick Your Plan & Stick With It

30 MIles in 30 Days

Declutter to Destress

Tobacco Cessation

Community Race Event

Gym Attendance (Average of 3 days per week for 8 weeks)

Other (please specify)

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* 7. Upload Proof of Completion (Hint... This can be as simple as a screen shot saved as a photo). Only PDF, DOC, DOCX, PNG, JPG, JPEG, GIF files are supported.

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.